Phase 1: Clarifying Symptomatic Phenomena and Establishing a Therapeutic Alliance

Patients begin therapy for a variety of reasons. Those with histrionic personality disorders often begin with a sense of urgency and a belief that presenting symptoms of frightening thoughts and images and out-of-control feelings of anxiety or despair can be quickly dispelled by the therapist. Recent traumatic events or episodes of abuse or loss may be the immediate precipitants of flare-ups of psychiatric symptoms. Even in the midst of such crises there may be a sense, although not one readily expressed in words as a clear complaint, that repetitive interpersonal patterns have led in part to the mixed causes of the current turbulence. In the beginning, it is important to set up and repeat a framework that can address not only chief complaints but also underlying characterological issues over the period of hard and persistent work needed to develop a more mature integration of personality.

Careful listening and questioning about all symptoms and salient interpersonal patterns can lead to a list of salient phenomena that can be explained later by individual case formulations. This is an open-ended list, with revisions indicated as more information is obtained. Empathy to the patient's suffering resulting from the symptoms is important. The patient's sense of being out of control over the experiences should also be acknowledged if it is present, without getting into a potentially difficult transference situation of seeming to take over control and rescuing the patient from all distress - a role the patient may offer to the therapist.

The goal is to provide just enough support to reduce the likelihood of self-impairing actions by the patient and help the patient feel less out of control. A plan for step-by-step dealing with problems can be very restorative. A trial of a few weeks of therapy alone may precede the prescription of antidepressant agents if the patient has a comorbidity with a major depressive disorder. Hospitalization may be indicated if there is a risk of suicide or other serious behaviors. Antianxiety agents, if necessary, should be given on a minimal, single-dose basis rather than in a blanketing dosage over weeks.